Addendum to the Supporting Statement for 0960-0045

Addendum to the Supporting Statement for Form SSA-795

Statement of Claimant or Other Person

20 CFR 404.702, 20 CFR 416.570

OMB No. 0960-0045

Background

Generally, SSA sends the paper Form SSA-795 to claimants in special situations where there is no authorized form or questionnaire, yet we require a signed statement from the applicant, claimant, or other persons who have knowledge of facts, in connection with claims for Social Security benefits or SSI. Additionally, SSA provides a PDF version of the SSA-795 on our website for the public to print, complete, and submit to SSA for processing. At this time, claimants must print the blank PDF and fill it out using pen & ink, or they need to use a typewriter to complete the form. As some handwriting is difficult to read, or illegible, these non-fillable versions of the form are inefficient and ineffective since SSA employees who cannot read the submitted form must re-contact the respondent prior to processing. In addition, the use of typewriters has decreased significantly, as other tools, such as personal computing devices, have increased in use.

SSA developed a fillable, printable version of the SSA-795, as some individuals may find it easier to use. The fillable version allows the respondents to complete the form electronically using a personal computer, or other computing device, print the completed form, and submit it to SSA. We developed this fillable version, as we want to ensure SSA provides effective communication and remains in compliance with the requirements of 45 CFR 85.51 of the Code of Federal Regulations and section 504 of the Rehabilitation Act of 1973. We propose the fillable PDF version as a more accessible modality. In addition, the new fillable modality will enhance our electronic services and recordkeeping efforts.

Revisions to the Information Collection

• Change #1: SSA intends to provide Form SSA-795 in a fillable PDF file on our website, in place of the non-fillable PDF version we currently provide. We propose to make all form entries fillable.

Justification #1: This change will allow the respondents to continue to print and complete the form by hand, or, alternatively, complete the form using a computing device, such as a personal computer or handheld (mobile) device, print, and submit to SSA for processing.

After OMB approves the addition of the new fillable version of the form, SSA will phase out the standard PDF versions from our Internet and Intranet websites and replace them with the fillable PDF file.

This action does not affect the public reporting burden.